Sedation, conscious





Definition

Conscious sedation, produced by the administration of certain medications, is an altered level of consciousness that still allows a patient to respond to physical stimulation and verbal commands, and to maintain an unassisted airway.


Purpose

The purpose of conscious sedation is to produce a state of relaxation and/or pain relief by using benzodiazepine-type and narcotic medications, to facilitate performing a procedure such as a biopsy, radiologic imaging study, endoscopic procedure, radiation therapy, or bone marrow aspiration.


Description

Sedation is used inside or outside the operating room . Outside the operating suite, medical specialists use sedation to calm and relax their patients.

If the patient is to undergo a minor surgical procedure, screening and assessment of medical conditions that may interfere with conscious sedation must be explored. These potential risk factors include advanced age, history of adverse reactions to the proposed medications and a past medical history of severe cardiopulmonary (heart/lung) disease.

Once it has been established that the patient would be a good candidate for conscious sedation, just prior to the surgery or procedure, the patient will receive the sedating drug intravenously. A clip-like apparatus will be placed on the patient's finger to monitor oxygen intake during the sedation. This oxygen monitoring is called pulse oximetry and is a valuable continuous monitor of patient oxygenation.

Dosing of medications that produce conscious sedation is individualized, and the medication is administered slowly to gauge a patient's response to the sedative. The two most common medications used to sedate patients for medical procedures are midazolam and fentanyl.

Fentanyl is a medication classified as an opioid narcotic analgesic (pain reliever) that is 50 to 100 times more potent than morphine. Given intravenously, the onset of action of fentanyl is almost immediate, and peak analgesia occurs with in 10 to 15 minutes. A single dose of fentanyl given intravenously can produce good analgesia for only 20 to 45 minutes for most patients because the drug's distribution shifts from the brain (central nervous system) to peripheral tissues. The key to correct dosage is titration, or giving the medication in small amounts until the desired patient response is achieved.

Midazolam is a medication classified as a short-acting benzodiazepine (sedative) that depresses the central nervous system. Midazolam is ineffective for pain and has no analgesic effect during conscious sedation. The drug is a primary choice for conscious sedation because midazolam causes patients to have no recollection of the medical procedure. In general, midazolam has a fast-acting, short-lived sedative effect when given intravenously, achieving sedation within one to five minutes and peaking within 30 minutes. The effects of midazolam typically last one hour but may persist for six hours (including the amnestic effect). Patients who receive midazolam for conscious sedation should not be allowed to drive home after the procedure.


Monitoring

Patient monitoring during conscious sedation must be performed by a trained and licensed health care professional. This clinician must not be involved in the procedure, but should have primary responsibility of monitoring and attending to the patient. Equipment must be in place and organized for monitoring the patient's blood pressure, pulse, respiratory rate, level of consciousness, and, most important, the oxygen saturation (the measure of oxygen perfusion inside the body) with a pulse oximeter (a machine that provides a continuous real-time recording of oxygenation). The oxygen saturation is the most sensitive parameter affected during increased levels of conscious sedation. Vital signs and other pertinent recordings must be monitored before the start of the administration of medications, and then at a minimum of every five minutes thereafter until the procedure is completed. After the procedure has been completed, monitoring should continue every 15 minutes for the first hour after the last dose of medication(s) was administered. After the first hour, monitoring can continue as needed.


Risks and risk management

The American Academy of Pediatrics (AAP) has established safe practice guidelines to manage conscious sedation without an anesthesiologist for minor procedures. These AAP criteria include (1) a full-time licensed clinician (nurse, physician, physician assistant, surgeon assistant, respiratory therapist) who is strictly and exclusively monitoring the patient's breathing, level of consciousness, vital signs, and airway; (2) standard procedures for monitoring vital signs; and (3) immediate availability (on site) of airway equipment, resuscitative medications, suction apparatus, and supplemental oxygen delivery systems.

If adverse reactions occur while using fentanyl, the antidote is a drug called naloxone. It provides rapid reversal of fentanyl's narcotic effect. The incidence of oversedation or decreased respiration is low using fentanyl if the medication is carefully titrated.

See also Pulse oximeter .


Resources

BOOKS

Behrman, R. Nelson Textbook of Pediatrics, 16th ed. Philadelphia: W. B. Saunders Company, 2000.

PERIODICALS

"Recommended Practices: Monitoring the Patient Receiving IV Conscious Sedation." Association of Operating Room Nurses 57, no. 4 (April 1993).

U. S. Department of Health and Human Services. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guidelines. Department of Health and Human Services Pub. No AHCPR 92-0032.

ORGANIZATIONS

American Association of Nurse Anesthetists. 222 South Prospect Avenue Park Ridge, IL 60068-4001. Telephone: (847) 692–7050. Fax: (847) 692–6968. E-mail: info@ aana.com.


Laith Farid Gulli, M.D.,M.S. Alfredo Mori, MBBS

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



Conscious sedation is administered by medical or pediatric specialists performing a procedure that may be diagnostic and/or therapeutic. It may be used in a hospital, outpatient care facility, or doctor's office.

QUESTIONS TO ASK THE DOCTOR



  • When should I stop taking my regular medications? When should I begin them again?
  • What side effects can I expect after the procedure? Nausea? Dizziness? Drowsiness? Is there anything I can do to ward off these side effects?
  • What are the risks of this procedure?
  • Which sedative will you use?
  • What steps will you take if there are complications?
  • Will I feel any pain?

User Contributions:

Lois
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Jan 20, 2008 @ 10:22 pm
Please help me by letting me know about any adverse psychological effects to having received Versed (Midazolam). I have searched the internet and cannot find any medical evidence to suggest that patients who receive Versed for invasive procedures or prior to surgery could experience long term negative psychological effects from the drug. However, I and several others have found that we have had negative psychological effects after receiving this drug in that we have become anxious, obsessive and angry. This has caused us to be placed on anti-depressants. Is there any medically sound reason why this might happen?
Deborah A.
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Jan 7, 2009 @ 5:17 pm
I was given "MAX" conscious sedation for prodecure for ICD (implantable cardiac defibrillator.) (I am very young 58!!)
It was great. Absolutely no side effects and do not remember procedure. Unfortunately, my Cardiologist informed me that this can not be used for many other procedures, otherwise, would have administered with ANY procedure.
Robert Duncan
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Jul 9, 2009 @ 10:10 am
Anesthesiologists are experts in this area of medical practice and have establish guidelines for sedation and analgesia by non-anesthesiologists. Please refer to the following article:

Anesthesiology 2002;96:1004-17.
teri
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Aug 9, 2009 @ 1:13 pm
What is the longest time that a patient should be dept under with conscious sedation. I was recently schedule for an I&D. The doc started the cs just as we were leaving the or waiting room to take me to surgery. As luck would have it there was some type of problem with the OR we were to use and it is my understanding the anesthesiologist kept me under for and hour an a half while waiting for the OR. I have no memory of any of this or anything thing that happened once they hung and started the drip for the little bag. My surgery was Friday at 3:00pm and I never woke again till Sunday afternoon 5:00pm. I have had conscious sedation severl time before and come out of it immediatley... even woke up while the were still stitching my toe shut. This time did not go so well... thanks for any information and advise you can offer.
Terry W
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Sep 19, 2009 @ 9:21 pm
I recently had conscious sedation with fentanyl and versed - I am having the anxiety type symptoms mentioned above. I have NEVER been this type of personality. It doesn't help that I specifically requested no amnesia inducing drugs (Versed) but was totally ignored. Now this inability to get a good night's sleep and anger and anxiety. Is there any other way than anti-depressants? I really would rather not go there as I feel I take enough pills as it is......... What could be the cause of this?
Nancy M
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Jan 18, 2010 @ 5:17 pm
I was scheduled for an initial appointment before schedule a colonoscopy. I was told that this appointment was just to fill out paperwork and an exam when asked if I would be getting any information. One of the only things I could think to ask was would I be "out" for the procedure. I do not do well with the meds - was given one very low dose once, I couldn't sleep for about two weeks as well as being rather agitated (putting it mildly) which is very untypical for me before then. I would only allow myself to drive the five minutes to work because I felt like ramming into something (didn't matter what). This agitation/rage lasted for several weeks. When I asked about not being out I was told there was no choice that I would be given Demerol and Versed. What happened to patient's rights? I do not trust them to not force it on me after I say no. Most procedures I have had a local or spinal anesthetic and have been wide awake and allowed to watch. A lack of information from the doctor or his nurse tells me they are trying to hide something they don't want me to know, which leads to a lack of trust.
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Mar 14, 2010 @ 1:13 pm
I have a friend who will be undergoing a bone marrow biopsy and people he has talked with have had this experience and reported great discomfort. I anticipate he will be having this procedure in the near future and am concerned that the amount of anticipation of pain is adversly affecting his decision for the intial test as well as compliance down the road. I am aware of the effects of Midazolam removing memory of the test and would think this would be ideal to ensure future compliance. Could you tell me if this is a reasonable and accepted practise for this procedure. I am under a time line here so would appreciate an answer as soon as possible. Also would you know of any facilities in Edmonton, AB, Canada who do this on a regular basis? Thankyou so very much.
SC
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Mar 16, 2010 @ 12:00 am
Usually adults don't get sedation for a bone marrow biopsy. He will have to discuss this with his doctor. He may be afraid of the BMB, but it's not too painful. If you don't have the sedation you can get up and drive home after you stay prone for an hour.

The kids get conscious sedation however, as my son had this. It's very gentle and he can obey instructions to move, etc. He seems sleeping but can open his eyes and even answer questions. When the doctor is done I tell him to go to sleep and he sleeps for two hours at least (unless they need his bed).
Anna
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Jun 20, 2010 @ 12:00 am
I recently had conscious sedation for removing a polype from my uterus and been kept under sedation for 90 minutes instead of the 45 minutes planned. Could the longer duration is what made me stomach sick all day long after the operation? And also, I'm experiencing sleep deprivation; sleeping only 5 hours a night instead of my usual 9 hours. Could it be related too?
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Sep 1, 2010 @ 4:16 pm
My grandson is going to have surgery to have a cyst removed from his hand. He is 10 months old. The doctor said he was using general conscious sedation. He does not take any medications and does not have any other health problems. This is safe? How safe? Is this the best for him/his age?
Carolyn
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Oct 29, 2010 @ 11:23 pm
Within the last couple months, I've been put under several times with Versed & Propofol for several medical tests including a Colonoscopy and EGD. I tend to be very sensitive to medications and do not tolerate morphine or most opiate type drugs. I've actually experienced extreme breathing difficulty. So far I can tolerate Versed and Propofol very well. The only thing I've noticed immediately after coming out of sedation is a bad headache. My question is this: Has anyone experienced a strange sensation during sleep like you are falling off a cliff and awaken suddenly frightened & heart racing. Since my recent V & P procedures, I've noticed this and it is frightening. I asked two of my physicians about this and neither had a clue nor had even heard of a patient with this type experience. It's happening to me & I know it must be happening to others as well. I'd like to know if it's induced by one of the two drugs or both. Please let me know. Thanks.
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Oct 6, 2011 @ 7:19 pm
This is actually not as rare as you might think. The feeling that you are having is due to your brain sending signals to the nerve-endings in your arms and legs (maybe even other places). Some people are just more prone to a type of sleep apnea...in short. The combo of drugs used causes our brain to be tricked into thinking that we are in an REM sleep cycle (this is the active dreaming time of a normal night)during this time we can interact with our surroundings without being totaly awake. Our brain may send signals telling our skeletal muscles to "wake up". That's why some people jerk upon falling asleep. I really wouldn't worry too much about it unless it is happening far beyond the surgery days. If for some reason it is happening more than about three days post-op I would discuss having an MRI done to rule out any neurological issues.
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Oct 27, 2011 @ 4:04 am
I underwent a colonoscopy which I had to ask them to stop because it was extremely painful. 0.075 Fentanyl also 3mg Midazolam were used. When I complained of the pain the Consultant gave me more sedative. I was fully conscious throughout, was not drowsy or even relaxed.
I am taking 10mg Paroxine daily.
Is it possible that the sedative did not work?? On reflexion, that it what it felt like. The consultant did not speak to me afterwards so I had no opportunity to ask questions. I intend asking for an appointment with her to discuss this, as now a barium enema is planned (according to the write up that was given to me afterwards)
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Nov 3, 2011 @ 11:11 am
My partner underwent Heller Myotomy using conscious sedation. He experienced several days of hallucinations. Is this unusual?
mike owen
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Feb 9, 2012 @ 9:21 pm
I avoid all things medical if possible, but at age 50 my medical research group got new insurance and I was assigned my first-ever PCP for an annual physical; I reluctantly submitted and the young doctor insisted that I get a colonoscopy..she wasn't taking no for an answer. I was concerned about the sedation medications because several of my friends had long-term memory loss after colonoscopy sedation (Versed/fentanyl) and I surely was not risking this. I did some research and found that,indeed Versed's amnestic effects can be very long-lasting, sometimes causing serious impairment. Do they lie to everyone about Versed? I scheduled the test and nobody mentioned Versed side-effects...I asked the GI doc if Versed had any side-effects; she said that it didn't..when I quoted numerous studies she admitted that Versed has a lot of problems, etc. She was actually surprized when I asked for my clothes so that I could leave.
June
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Aug 21, 2012 @ 1:01 am
I was given Fentanyl and Versed during/in prep for colonoscopy. I was not told the sedation that I would receive, only that it was 'conscious sedation'. I have no memory of the colonoscopy. I hate that feeling and not being given an informed choice. I am very sore in my anal area, have nightmares (I haven't had nightmares since I was a child), headaches and nausea that won't go away. I get very anxious, scared feelings, feel as if I want to cry all the time. I have never been depressed or on medication for that, but sometimes feel like I am losing my mind since the colonoscopy. What did the doctors and staff do to me that they want me to forget? That is all Versed is used for, to make you forget. What did they do? Do you guys know that Fentanyl is 50-100 times stronger than morphine? Who needs anything that strong?
Roxana
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Oct 30, 2012 @ 8:08 am
I did both a colonoscopy and upper endoscopy and I refused the conscious sedation for both. They told me I would be sedated and I just politely asked if they could do it without sedation. The doctor warned me that it might be really unpleasant and/or painful but he agreed to try it without sedation. The colonoscopy was fine, uncomfortable, but not unbearable. He let me watch the screen the whole time and explained everything I was seeing. The upper endoscopy was really unpleasant but it was over in a few minutes and I got through it. I definitely don't think it would have been worth it to get sedated for either. It was really nice to just get up off the bed and walk away instead of having to recover from sedation meds. I'm glad the doctor respected my choice to not be sedated. I think the doctors just assume you want to be sedated, but if you ask politely and don't sound frantic or anxious they will often agree to do your procedure without sedation. If your doctor won't respect your decision, find another doctor!
jerry
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Nov 15, 2012 @ 9:21 pm
Several of my friends have had terrible experiences with "concious sedation" and the culprit is Versed; they experience wakefulness but unable to communicate the pain that they are experiencing. So-called sedation for simple procedures such as colonoscopy is pushed onto patients as: "we will give you something to make you sleep comfortably" which is total BS..they are usually awake and in agony because of a rushed exam; the provider smugly assumes that) but I will no long the Versed amnesia will insure a compliant patient and get them out the door...let the anxiety, PTSD, nightmares, agression, occur when the patient gets home! I would NEVER consent to receiving VERSED nor would I recommend it to my patients (I have convinced hundreds of my patients to get a colonoscopy but I will no longer do so unless the "sedation" is propofol only administered by an anesthesiologist, not a CRNA (nurse)
Mary
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Jan 26, 2013 @ 3:15 pm
I just got home fronm having a Heart Catherization. I was having a heart attack Wednesday night and in this town they will not take you to the Big Med center where all the great heart docs are (including mine) I had no idea I was going to be given VERSED to shut me up, I was told. Versed was used on me years ago and I thought I was going to die. I had forgotten about that med but I was told another med would be used if need be. I was told a heart cath had to be done ASAP and there was no way I could get to the Heart doctors 20 minutes a way...I am having trouble breathing. I cannot take a deep breath almost like gasping for air. I was also sweating. I am 74 and do notthink this Cath doctor shoul dof usded this on a elderly person. He gave it himself while doing the cath asd there was only a female tech in the room at 2:00AM. Reading these forums I am mad he usaed this himself. When i had a heart catrh 5 years ago the Interverntionalsit Cardio doctor has an MD anesthesiologist inthe room. They used propofol. When I had an EGD a month ago at the same great hospital the gastro lady used only Propofol. I did great on Propofol. I should og insisted on the 20 minute dri8ve to the Heart center instead of the small hospital who does not have all the answers. I hope this clamminess and poor breathing leaves me soon.
TampaBayTim
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Apr 2, 2013 @ 8:08 am
I am scheduled for a CT Myeleogram (2nd test in 4 years) the first test went well as I was Moderately Sedated and kept comfortable although it was painful, it was bearable even with the sedation. Now I have to undergo another CT Myeleogram and the Neurosurgeon typically does not prescribe consciention sedation. I called the Neurosurgeons office and explained that I would prefer conscientios sedation. He was on "trauma duty" and his nurse could not get ahold of him to discuss my sedation request. She did however suggest that I call my regular family doctor and have him place the order for "moderate sedation" during the procedure. Since my 1st test I have had implanted Spinal Chord Stimulator into my spine. I know this will contribute to the pain that I am going to experience and feel that the neurosurgeon should have ordered the moderate sedation in the 1st place. Now taking his nurse's advice I have contracted my Family "Primary" doctor and asked if he would prescribe sedation. The primary doctors' nurse called and told me that "the doctor wanted to know what type of sedation I wanted". As I am not a medical professional, what should I tell him? I need pain control and something to help with my nerves. DOES ANYONE KNOW WHAT TYPE OF MEDS I SHOULD TELL HIM THAT I WANT (NEED) TO GET THROUGH THIS PROCEDURE? TIME IS OF THE ESSENCE AS THE TEST IS SCHEDULED IN A FEW DAYS. ANY INPUT FROM ANY MEDICAL PROFESSIONAL WOULD BE HELPFUL. Thank you so much for answering.
kathy
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Dec 4, 2013 @ 10:22 pm
After reading the comments on the sedative. It scares me as far as the side effects alot have complained about. I just had a upper GI scope done monday. And the only thing ive noticed has been nightmares thats wake me up. Also lake of sleep. And ive been sick to my stomach since. But,How long will these side effects last? And if i notice any of the other side effects what should i do?
Sharon
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Jan 5, 2014 @ 5:05 am
I'm a 36-yr old medical professional and I had a colonoscopy performed 3 days ago (cancer screening - long family history) with Versed and Fentanyl with no adverse effects. I do not remember the procedure nor have any lingering issues. There was no pain afterwards either. I'm surprised at the comments here. Versed is a benzodiazepine (like valium but more soluble), which is considered to be a rather safe class of drugs. I have never seen any type of anxiety, PTSD, nightmares, aggression after use of either drug in my 12 yrs of experience. But I will definitely be looking for it more after these comments. I have only found a few reports of adverse behavioral changes in patients.

For example: "A 49-yr old female sedated with midazolam developed severe aggressive behavior during insertion of implants, which increased with further increments of midazolam. This paradoxical reaction was terminated by the injection of flumazenil, after which the patient calmly underwent the procedure." Reports are few and these effects seem rather short-lived and/or reversible. I find it odd that any lengthy paradoxical effects would last enough to be prescribed meds. Indeed, Versed (aka midazolam) is useful for treating agitated or combative behaviors (as well as seizures - muscle relaxant).

I did see an about.com article on Versed (and I dislike about.com because I've found quite a few things that are flat-out wrong on there by so-called experts) that said "a small minority of patients feel agitated, hyperactive or combative when taking Versed, rather than the anxiety relief and relaxation that is intended." But while it doesn't say so, this seems to be based on reports of in-procedure reactions, not prolonged after surgery. For those experiencing these, I would definitely suggest having further work-up. I also acknowledge that adverse effects are very likely under reported, but I couldn't find anything on lasting behavioral changes so I hope that means that those experiencing these problems will only have to deal with them temporarily. But get checked out!

But to be sure, I did have a "Twilight" sedation many years prior (~15yrs) that was awful. I have no idea what they used but I remember some of the procedure, then later trying to wake up, unable to see (I assume because I couldn't figure out how to open my eyes), scratching the wall beside my bed, and begging for help. I could hear a nurse come in and she ignored me, until I finally got her to answer about how the procedure went. She was brusque and rude. My t1houghts are that they likely did not do a good job of titrating the meds they used on me because they either didn't care, use the same amount for every patient whether or not it was effective, and/or were in a hurry. I was rather rushed and pushed into having the procedure done, I was distraught, and not well informed at the time. I have gone into the medical profession since and will always remember how I was treated and felt. It was not acceptable.

I think it is best to vet the staff at whatever facility you use for whatever procedure you are having. If they don't care or take the time to answer your questions then you aren't getting good care. It can make all the difference!
Cindy
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Feb 24, 2014 @ 6:18 pm
The type effect that the first person is describing would be more from a steroid instead of versed. They give Prednisone for nausea sometimes and I would guess that the prednisone was what caused the anger and change in personality. Versed and Fentynal are very safe for conscious sedation. There are many people though who have adverse effects from steroids.
Martin
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May 9, 2014 @ 10:10 am
I experienced severe pain at the site of where I was administered conscious sedation. I had intense pain and had chest pain just prior to going under. I have had conscious sedation before and never had this experience.This frightened me badly.What caused this to happen?
michele
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Aug 7, 2014 @ 6:18 pm
Yesterday I had eye surgery and was under concious sedation.It was the best.I felt nothing and still do not remember the surgery.I also had no side affects today.I would request this type of sedation again, but hopefully I won't have to.
Kim
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Sep 18, 2014 @ 12:12 pm
My father is a 68 year old who underwent hand surgery in early February. He was administered Ancef, Versed, and Fentanyl during the surgery. Ever since his surgery, he has gone from specialist to specialist trying to figure out why his personality has changed. He has had extreme anxiety ever since the surgery. He has been given all different kinds of meds to sleep, to descrease anxiety, and anti-depresents. His body has had horrible adverse effects from all of the medication. Each medication that he has tried, his body has respononded with all of the listed side effects. He was not like this before his surgery. He has become extremely dependent on others and has totally given up at this point. There are times where he can't even speak, because he has panic attacks and he can't walk either, as his body moves into flight or fight mode. He travelled often, was really active, and and enjoyed socializing with others on a consistent basis. Now, he refrains from all of this. He has complained of a horrible headache ever since the surgery as well. Doctors have continued to say that this is from the anxiety. He never had this symptom before surgery either. My family is wondering what are options are, as his quality of life has gone to an all time low at this point. What types of treatments are available?
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Oct 23, 2014 @ 3:15 pm
Yesterday morning I had a colonoscopy. I explained all my meds to the nurse and she made sure the doctor knew about them. I have had PTSD for 18 years since the murder of my 22 year old daughter . She was assulated and murdered while working for a new home builder. I also worked for the same buildrer. I take antidepressive meds for that and 2 dics have been removed from my neck and replaced with metal and I have 2 bulging dics on my lower back. For this I take 2 15ml oxycodone a day. Once upon waking and another in the afternoon. This was all disclosed. The nurse put the fentanyl and versed. They told me they had a doctor in the room that would do more medication if needed. At the beginning when they just started the plain was ,excruating!.. I screamed or yelled very loudly. they told me to relax. How could I, this was the worse pain I have ever had, probably worse than when I had my children. Remember when they gave you nothing until the baby crowned. Everytime they moved the tube my insides tied in knots and cramped severly. Finally I yelled stop. Suddenly I woke up with a full mask on my face. They told me before that if I had the mask on the other overseeing doctor had given me more of something. I can only think of the forgetable medicine. I remember the doctor asking me if I had ptsd for long and I told him yes. Afterwards even before the doctor had left me I apologized about the screaming. I was embrassed. He said to me”Do you remember that” I said of course. He thought I would forget the question of ptsd and the pain. What are they doing while you are there that they have to give you a drug to forget the procedure. That is like a date rape drug. I would not want any of my children to experience that kind of pain and have it erased from their mind. If a tree falls in the forest does it make a sound. thank you, Peggy

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